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Brazilian Journal of Cardiovascular Surgery

On-line version ISSN 1678-9741

Rev Bras Cir Cardiovasc vol.21 no.1 São José do Rio Preto Jan./Mar. 2006 



Evidenced based medicine



Wilson Daher*



The current tendency in medical practice is directed towards what is denominated as "Evidenced Based Medicine" (EBM), idealized by the British epidemiologist Archibald L. Cochrane in 1972. We know that its goal is to focus on medical science in a more positive way, based on the consistent metaanalytic data available to research, in such a manner that medicine would be considered and exercised only by scientifically proven parameters using data from reliable sources.

There has been a constant discussion on this theme, as we are currently becoming invalidated by the broadly technical implementation of the medical profession, which to a certain extent is in opposition to those professionals who still excel in the solitary physical examination at the patient's bedside, based on their knowledge of physiology and physiopathology. The conflict created between the old and the new generations of physicians resides in exactly this point, in that medicine would also stop to be an art if it were guided only by metaanalytically established scientific parameters.

This work does not intend to question if there is still a space for medicine as an art, even though the author recognizes that given the singularity of each patient, that statistics, as welcome as they may be, will never mirror the personal universe of each individual with their own subjectivity and individual biology.

Medicine was born as an art and, as such, since the time when 'home made potions' were used to alleviate pain and cure diseases, it has been gradually diverging from this to penetrate into so-called scientific truth, naturally subjected to the natural questioning of whom exercises.

If today EBM is a reality that has come to stay, it is not correct that we forget those who came before us. It is obvious that in the development of the history of medicine, nobody could forget names such as the chemist Pasteur, Kock, Lister, Loeffler, Chagas, Halsted and so many others who we confess decisively contributed to remove medicine from the darkness of ignorance and transform it into an elucidated science which used to be evaluated mythically and philosophically. There are others however, that did not count on premises to establish their new ideas. There performance was based on a decisive factor that we call privileged intuition that is an attribute that few illuminated individuals have, who put science to one side as a mere contemplation to observe and sense what many centuries after would be confirmed as scientific fact.

From intuition to scientific fact, the path that we believe led to the structuring of EBM, there were many sacrifices. Authors had to struggle for an indeterminate time against the arrogance, intolerance, anger and envy of their peers that, with rare exceptions feared being removed from the pedestal on which physicians had placed themselves. Who can not remember the intolerance of Virchow in the middle of the 19th century, who did not accept the theory of contamination by touch suggested by Semmelweiss, notwithstanding all the evidence of his excellent results in the reduction of death by puerperal fever? And why? Because if accepted, the proposal by Semmelweiss would destroy his sacred theory of cellular pathology, that attributed the source of all diseases to the cell.

Semmelweiss was an example of an individual gifted with privileged intuition, as without any premise on which to base his ideas, he 'saw' the infection entering into the depths of pregnant women, on the hands of the physician and students who examined the results soon after in the morgue. Soon after, his intuition (feeling and irrational perception that something was happening) was transformed into scientific fact by Pasteur who identified by microscopy the invisible assassins that today we know as streptococcus.

A long time before Pasteur, however, at the end of the 15th century, in Verona in Italy, the poet-physician Fracastoro, sensed an infection by direct or indirect contact by means of invisible seeds, which he denominated seminária prima. Although ridiculed for believing things that could not be seen, Pope Clemente VI supported him by signing a decree prohibiting contaminated prostitutes and courtesans from exercising their professions, thereby reducing the incidence of syphilis and tuberculosis etc.

We could cite numerous professionals from the health services that intuitively contributed to the future scientific fact, that culminated with Evidenced Based Medicine: Horace Wells, in the 19th century had the intuition that nitric oxide could be used as an anesthesia; William Harvey in the 17th century and the privileged intuition that venous return could only occur by means of micro arterio-venous anastomoses which was later microscopically proved by Malpighi, etc.

Evidence (from the Latin evidential) means clarity, visibility, indispensable virtues for the logical exercising, rational of medicine and it is thus that it is imagined henceforth. It seems there is no more space for the solitary work of the physician and his personal opinions distant from the previously catalogued evidence. However, as is seen in one passage of a book written in 1920 by Lima Barreto (Dairy of a Madhouse), written at the time of his hospitalization for psychiatric treatment for alcoholism, we can still perceive generations of physicians manipulated by the "already done and already determined" mentality without any influence of their personal evaluation.

"I had suspicions that he [that young physician] would like to try a new drug on me with his hurry and his sweet talk. He did not seem able to put forth his own opinion, so that he could transform into his own idea that, which had until then, come from heaven knows where, but to his eyes had shown the truth. It was then that I saw there the misfortune and the wretched himself...."

In this passage, Lima Barreto, so up-to-date, stressed the evidence of the necessity of transforming established truths, into personal thoughts (or not) and we think that this is the exact point in which science and art should never be separated under a sentence that medicine will be transformed into a true technocracy and we, the physicians, as simple depositors of the famous education bank to which Paulo Freire in the second half of the last century referred to in his masterpiece "Education of the oppressed".



* PhD student. Psychiatrist. Professor of the history of medicine of the Medical School in São José do Rio Preto - FAMERP

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